NCT01811173

Comprehensive-Care for Multimorbid Adults Effectiveness Study

The Clalit Comprehensive-Care for Multimorbid Adults Project

• Status: Unknown
• Phase: N/A
• Study type: Interventional
• Enrollment: 1,800 (estimated)
• Sponsor: Meir Medical Center · Academic / Other
• Sex: All
• Age: 18 Years – 95 Years
• Healthy volunteers: Not accepted

Summary

This study is intended to examine whether directed care of a nurse working jointly with the patient's primary care physician, including a comprehensive assessment, creation of a tailored care plan, proactive follow-up, self management support and caregiver support and care coordination, can reduce hospital admissions for patients with multiple chronic conditions.

Detailed description

Patients with multi-morbidities pose a significant challenge for healthcare organizations because they require continuity of care among a wide range of long-term therapeutic paradigms for many different types of diseases. The current study is based on a treatment model entailing a nurse-primary care physician team to provide care for patients with multiple morbidities. Patients in the intervention group who agreed and signed the consent form to participate in the study will receive treatment by the physician - nurse team in accordance with the components of the Clalit's Comprehensive Care for Mutlimorbid Adults Project model. Components of the intervention include: 1. Comprehensive assessment of the patient's and family's needs 2. Coordinated care plan based on integrated care guides 3. "Multimorbid Action Plan" for patients 4. All-inclussive patient centered care and caregiver support 5. Proactive monitoring according to the plan. Patients in the control groups will receive usual care in their primary care clinics. The Usual Care Survey control group will complete study questionnaires at 6, 12 and 24 months after enrollement. The Usual Care Blinded group will be assessed only retrospectively based on deidentified information from Clalit's admistrative databases.

Conditions

• Chronic Disease

Interventions

Type	Name	Description
OTHER	Nurse-physician comprehensive care	Components of the intervention include: 1. Complete assessment of the patient's and family's needs conducted by the nurse. 2. Comprehensive treatment program developed by the nurse and in consultation with the primary care physician. 3. "Multimorbid care plan" integrating all care aspects. 4. "Action Plan" for patients, supporting self management 5. Proactive monitoring according to the plan.

Timeline

• Start date: 2013-03-01
• Primary completion: 2017-03-01
• Completion: 2017-03-01
• First posted: 2013-03-14
• Last updated: 2015-04-29

Locations

13 sites across 1 country: Israel